A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Concrete operational: This stage (7 to 11 years) is characterized by logical thinking about concrete events.
B. Sensorimotor: This stage (birth to about 2 years) is when infants learn about the world through their senses and actions. Object permanence—the understanding that objects continue to exist even when they cannot be seen, heard, or touched—develops in this stage.
C. Formal operational: This stage (12 years and up) involves abstract and moral reasoning.
D. Preoperational: This stage (2 to 7 years) is when children begin to engage in symbolic play and learn to manipulate symbols, but they don’t yet understand concrete logic.
Correct Answer is D
Explanation
A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.
B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.
C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.
D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.
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